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HIV Infection among Refugees: Myths and Findings HIV Center for Clinical and Behavioral Studies NY State Psychiatric Institute and Columbia University.

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Presentation on theme: "HIV Infection among Refugees: Myths and Findings HIV Center for Clinical and Behavioral Studies NY State Psychiatric Institute and Columbia University."— Presentation transcript:

1 HIV Infection among Refugees: Myths and Findings HIV Center for Clinical and Behavioral Studies NY State Psychiatric Institute and Columbia University December 10, 2009 I want to thank you for inviting me to come speak about HIV infection among refugees, Myths and finding Susan Temporado Cookson, MD, MPH International Emergency & Refugee Health Branch Centers for Disease Control and Prevention

2 Overview Definitions Risk factors impacting these populations
Emergencies Refugees and internally displaced persons Risk factors impacting these populations Big 4 communicable diseases HIV Myths, findings, and realities Principles of HIV control among refugee and internally displaced populations Over the next 45 minutes I will first explain some of the terms that I will be using throughout the rest of this talk Such as what are emergencies and Who are refugees and internally displaced persons, the vulnerable populations that are created as a result of these emergencies Then give a brief background of the conditions impacting these vulnerable populations, giving the basic communicable diseases and then for the rest of the talk concentrating on HIV Presenting possible myths or realities And available findings and possible reasons for these findings depending on the phase of the emergency And finally look at principles for HIV control again depending on the phase of the emergency

3 Definitions of Emergencies
Emergency: unforeseen crisis requiring immediate response Natural disaster: vast ecological breakdown between humans and their environment; such a serious or sudden event that the community needs extraordinary efforts to cope, often with outside help or international aid Complex humanitarian emergency (CHE): large-scale human displacement with living condition deterioration caused by physical conflict, often with attempt to restructure society (e.g., genocide), leading to significant increase in mortality for limited time, but sometimes longer Indicator = 1 death /10,000 population / day So let’s first look at emergencies In general , an emergency is an unforeseen crisis requiring immediate response They can be divided into two major types Natural disaster: vast ecological breakdown between humans and their environment, such a serious or sudden event that community needs extraordinary efforts to cope, often with outside help or international aid Complex humanitarian emergency (CHE): large-scale human displacement with living condition deterioration caused by war or attempt to restructure society (e.g., genocide), leading to significant increase in mortality for limited time, but sometimes longer We use the indicator of >=1 death /10,000 population/ day to define that the situation is in an emergency phase

4 Definitions of Refugees and Internally Displaced Persons (IDPs)
Both populations Victims of conflict and violence Fled their homes Fear of or persecution Race, religion, nationality, member of social group, political opinion, gender Refugees only Fled outside home country Unable/unwilling to return home But now let define the terms of refugee and internally displaced persons or IDPs Both are victims of conflict and violence Both have had to flee because of fear or actual persecution on the basis of Race Religion Nationality Being a member of a social group Having a political opinion or Gender Internally displaced persons remain within their country of home But refugees have fled to outside their country and because of being a victim of persecution are unable or unwilling to return home

5 Population Movements in Conflicts of Refugees and Internally Displaced Persons (IDPs)
This schematic helps explain the difference between refugees and internally displaced persons or IDPs As you can see both are affected by the conflict However, IDPs do not cross the international border and refugees do. IDPs who interact with the host community, are interacting with people of their same nationality For refugees, any interaction with the host community would be with persons of a different nationality In regard to HIV transmission, in addition to interacting with the host community these persons can also have interactions with other key groups such as armed forces and UN peacekeepers sex workers In the post-conflict phase, IDPs return to their homes in the same country For refugees, they would repatriate back to their home country or country of origin or integrate into the host population

6 Communicable Diseases Risk Factors among Refugees and Displaced Persons
Mass population movement Ongoing conflict/insecurity Gender-based violence Temporary/absence of shelter Poor nutrition/scarcity of food Poor healthcare access/collapse of healthcare Lack of medications/treatment Lack of prevention/control programs Of supplies, such as condoms or vaccination Of programs, such as TB or HIV control So what are the communicable diseases risks among these persons Most suffered from mass population movement, as so well seen in the Balkans in the 1990s Many have experienced Gender-based violence They live in Temporary shelter or can even lack any shelter, as seen among the Sudanese youth in the 1980s and 1990s As a result they have a Poor nutritional status and scarcity of food In addition, there is poor access to healthcare or a collapse of the healthcare system, leading to lack of medications and treatment Leading to a Lack of prevention and control programs With Low immunization coverage and lack of vaccination Lack of condoms or vaccination Lack of TB and HIV/AIDS control Serbians fleeing Source: Connolly MA, et al. Lancet, 2004

7 Communicable Diseases among Refugee and Displaced Persons
Big 4 causes of morbidity and mortality Acute respiratory infections Diarrheal diseases Measles Malaria Malnutrition HIV/AIDS have increasing importance But not top priority in emergency Potential regional effects Disease prevalence, including HIV The main causes of morbidity and mortality among refugee and displaced persons are Acute respiratory infections Diarrheal diseases Measles, if the vaccine coverage is low And malaria, if endemic in the area and the population naïve However, TB and HIV/AIDS have an increasing importance Especially for children and women in regard to violence and children and the elderly with the interaction of TB with malnutrition And all of these diseases can have regional effects in regard to the prevalence of these diseases

8 Vicious Cycle of Micronutrient Deficiencies and HIV
Insufficient dietary intake Malabsorption and diarrhea Altered metabolism and impaired nutrient storage Micronutrient Deficiency and HIV Cycle Increased HIV replication Disease progression Increased morbidity/mortality Micronutrient deficiencies As seen in this slide, micronutrient deficiencies and HIV form a vicious cycle where each condition worsens the other. A component of the Insufficient food intake, either because of lack of appetite or lack of food and then malabsorption Lead to micronutrient deficiencies, Immune suppression and Progression of disease This cycle results in: - Weight loss - Loss of muscle tissue and body fat - Vitamin and mineral deficiencies - Reduced immune function and competence - Increased susceptibility to secondary infections - More rapid HIV disease progression People affected by conflict lack nutrition and micronutrients, People with HIV need more calories, protein, micronutrients than the average person in these emergencies 300 to 1000 kcal more per day and % more protein Increased oxidative stress Immune suppression Modified from Semba RD and Tang AM. Brit J Nutrition, 1999

9 Reasons HIV Not Top Priority in Emergencies
Perceived as development issue Concerned of discrimination against HIV-infected refugees Basic survival: shelter, food, water, sanitation Health actions focused on Big 4 and malnutrition Essential primary clinic services/medications So here is HIV not considered a top priority in emergencies It is perceived as a development, not emergency issue Fear exists that if addressed and people identified, there will be discrimination against HIV-infected refugees And that basic survival needs of shelter, food, water and sanitation need to be addressed first And the health actions focused on the big 4 and malnutrition by ensure essential primary clinic services and medications are offered

10 Refugees and Internally Displaced Persons, 31/12/08
Population * 1,000,000 Total=24.9 million Internally displaced 14,405,405 Refugees 10,478,621 Looking at he epidemiology of these populations the UN High Commissioner for Refugees or the UN Refugee Agency, publishes yearly data Their most current figures from the end of 2008 Revealed 25million total of whom 14.4 million are internally displaced 10.5 million are refugees The regions where the most come are Africa, Middle East and Asia and as you know these are the regions with the most HIV For the remainder of the talk, I will mainly focus on Africa because it is both where the majority of refugees and IDPs reside and because it has the higher rates of HIV infection Source: UN Refugee Agency Global Trends. Available at:

11 Myths or Realities? Conflicts increase HIV transmission
Refugees bring HIV to the country of asylum IDPs and refugees have the same HIV risks and prevalence rates So let’s now look at some of the myths or realities surrounding these emergencies and the populations the emergencies impact We will look at 4 Conflicts increase HIV transmission among the populations affected Sexual violence during these emergencies increases the HIV prevalence Refugees bring HIV to the country of asylum or host country IDPs and refugees have the same HIV risk and therefore, the same prevalence rates

12 Effects of Conflict and Sexual Violence on HIV Transmission and Visa Versa
Difficult to discern Wide variety of issues involved Data can have varied quality and focus, be biased Data on prevalence on HIV and sexual violence among affected-populations scarce I first want to start with a caveat The effects of conflict and sexual violence on HIV transmission Are difficult to discern There are a wide variety of issues involved, some of which I will try to present and explain In addition, the data can have varied quality and focus and therefore may be biased And the data on prevalence on HIV and even more so sexual violence among these affected populations are scarce

13 1. Do conflicts increase HIV transmission?
That said, Number 1 – do conflicts increase HIV transmission

14 Epidemiology of Conflicts and HIV
Overlap between countries affected by conflicts and high HIV prevalence , 2004 HIV Prevalence in Africa, 2007 There have been 2 studies that have indirectly looked at this. The first by Nancy Mock, et al showed that With a few exceptions, the countries with major conflicts in 2004 like Angola, DRC, Sudan, Somalia actually have lower HIV rates and countries with relative peace like Namibia, South Africa, Zambia have higher HIV rates. I have shown the most recent UNAIDS HIV data of 2007 but, these trends have been true since the study was done in 2004 Sources: Mock NB, et al. Emerg Themes Epidemiol, 2004 UNAIDS Report on the global AIDS epidemic

15 Level of Conflicts and HIV Prevalence 1991-2000
Among 37 sub-Saharan African countries Armed conflict scores vary from 0, no conflict, to 28 and 29 for Sudan and Angola, respectively 15 countries with no conflict, including Botswana, Central African Republic HIV prevalence=18.6% 13 countries with armed conflict score=1-9, including Cameroon, Senegal HIV prevalence=8.3% 9 countries with armed conflict score>10, including Burundi, DRC, Somalia HIV prevalence=7.8% The other study by Roland Strand looked at 37 sub-Saharan African countries over a 10 year time period And classified each according to level of armed conflict, with scores from 0 for no conflict to a high of 28 and 29 for Sudan and Angola, showing a pattern similar to what Mock recorded And found among the 15 countries with no conflict, such as Botswana, Central African Republic, Malawi, South Africa Had an average HIV prevalence of almost 20% Among the 13 countries with some armed conflict, such as Cameroon, Chad, Ethiopia, Senegal Had an average HIV prevalence of 8.3% And among the 9 with major armed conflict, such as Angola, Burundi, DRC, Somalia and Sudan Had an average HIV prevalence of 7.8% Source: Strand R, et al. Int J STD & AIDS, 2007

16 Strand R, et al. Int J STD&AIDS, 2007
Spearman rank correlation, г=-0.41, p=0.012 So looking at these data plotted out we see a significant correlation between level of conflict and HIV prevalence – the greater the conflict the lower the HIV prevalence rate per country with rho = and p-value of 0.012

17 Why do conflicts seem to delay HIV epidemic?
Two stages of conflict Conflict Survival Access Post-conflict Services and employment So if we assume that conflicts actually delay the HIV epidemic, the question becomes why Well that depends on the stage of the conflict that we are talking about Be it during the actual conflict or in the post conflict period During the actual conflict questions of actual survival and levels of access to populations and services or even sexual activity and violence need to be asked During the post-conflict stage, services, employment and access also need to be investigated questions of greater access to the population and to the demobilized military forces and peacekeepers and again the level of sexual activity and transactional sexual need to be asked

18 Conflict Stage Survival of HIV-infected persons Isolation
Differential mortality among high-risk populations In addition, poor nutrition and lack of services Isolation Destroyed transport, unsafe travel, disrupted commerce Level of sexual activity Marked reduction KABP among Rwandan refugees, Tanzania 1994 Decreased libido Depression and post-traumatic stress symptoms So during the actual conflict HIV-infected persons probably have a differentially higher mortality as some other high-risk populations, such as young children and the elderly In addition, poor nutrition and lack of services, adds to their mortality rate And conflicts lead to isolation of the populations because of Destroyed transport, unsafe travel, disrupted commerce sexual activity may actually decrease, as one knowledge, attitudes, behaviors and practice survey among Rwandan refugees in Tanzania in 2004 showed And multiple studies have showed high rates of depression and post-traumatic stress symptoms that can lead to decreased libido among these populations Source: Mayaud. Trans Roy Soc Trop Med & Hyg, 2001

19 Post-conflict Stage Increased HIV incidence , post-conflict
Maputo, Angola (9.9% in 1998, 13.2% in 2000, 20% in 2004) Service may be slow Quality of medical services Supplies, equipment/vaccines, and medications Universal precautions, safe medical equipment and blood may lag Level and type of employment Demobilization of forces and female head of households Access Urbanization and increased level of sexual activity Increased HIV incidence has been seen in the post-conflict stage in such countries as Angola, Mozambique and South Africa As the conflict resolved the level of HIV prevalence has increase, it may be just the epidemic maturity or may be related to great access Other reasons for this may be Service delivery may be slow Quality of medical services that now exist may be poor, with poor access to supplies, such as condoms, equipment and medications Lack of Universal precautions, safe medical equipment and blood may lag Employment levels may also wane with many demobilized military forces and peacekeepers returning, there many be a large number unemployed In addition, female heads of households may need to turn to transactional or commercial sex practices Increased access may also lead to mixing of populations with previously isolated populations going to cities and increased levels of sexual activity also leading to increased risk of HIV Source: UNAIDS/WHO. AIDS epidemic update. Geneva: UNAIDS/WHO, 2004

20 2. Do refugees bring HIV to the country of asylum?
So the next question, be it myth or reality, is do refugees bring HIV with them to the country of asylum?

21 HIV/AIDS: Epidemiology among Refugees
HIV prevalence among refugees appear lower than host population – Country of origin compared with country of asylum When we look at specific regions with at least 10 countries having refugee populations of at least 10,000 in 2004 The HIV prevalence among refugees as compared with the host population for the 3 regions with refugees Showed that the HIV prevalence among the refugees as far as their country of origin was equal or lower than where they current reside in their country of asylum in Africa, Asia and Europe Therefore, in spite of the lack of security and gender-based violence Lack of prevention programs, such as condoms that led to them becoming refugees Poor healthcare assess and lack of treatment for sexually transmitted infections The situation must be more complex and other factors must be at work * Weighted means: country of asylum by population size, country of origin by refugee population size Source: Spiegel PB. Disasters, 2004

22 HIV Prevalence Data among Refugees
Surveillance during conflict impractical Surrogate data Adults: chronic diarrhea, fever of unknown origin, recurrent pneumonia, STIs, TB, wasting Children: chronic diarrhea, developmental delays, failure to thrive, recurrent bacterial infections Direct HIV testing results Blood supply: no systematic surveillance Antenatal care centers But, first Surveillance for HIV prevalence rates during conflict are impractical But, Surrogate data can be collected For Adults: chronic diarrhea, fever of unknown origin, recurrent pneumonia, STIs, TB and wasting For Children: chronic diarrhea, developmental delays, failure to thrive, recurrent bacterial infections In refugee settlements in Uganda, many children are on therapeutic feeding with no signs of gaining weight. Talking to the nutritionist in October last year, he felt it was because of HIV but had no way to test for it and no ARTs if he was able to test for it Direct means of determining the HIV prevalence might be available from data during testing of the blood supply for medical use but no systematic surveillance system exists with results In addition, VCT and PMTCT data might be available

23 UN Refugee Agency Health Information System (HIS)
In 1999, began development In 2006, 16 countries with stable refugee camps Data collected: Blood supply activities: no results VCT (PICT), PMTCT, And ART program activities Evaluation in Sept-Nov 2008: Issue with data quality No possible source of these HIV prevalence data might be available from the UN High Commissioner for Refugees Health Information System My branch began development of this system with the UN Refugee Agency in 1999 By 2006, the system has been implemented in 16 countries with stable refugee camp situations From the HIV standpoint, HIS collects data on blood supply activities but no results of the screened blood units are collected In addition, volunteer counseling and testing, which is actually provider initiated counseling and testing, data are collected but this does not indicate general population rates Preventing maternal to child transmission activities and ART program activities, Are or are to be in the case of ART programs captured, but after CDC conducted with UNHCR an evaluation of the system last year, what data are available are of questionable value Source: UNHCR. Health Information System (HIS) toolkit Available at:

24 Assess HIV Prevalence Rates, Africa
Method Anonymous, unlinked, cross-sectional surveys (UAT) Attendees public antenatal clinics, including in refugee camps First time Blood for syphilis testing Often no informed consent Concerns of selection/participant bias De-identified, except for Age, parity, marital status , educational level , and clinic location (or urban versus rural) In refugee camps: refugee versus host status Rapid, diagnostic tests and/or dried blood spots Therefore, the HIV prevalence data that are available in Africa, are from Anonymous, unlinked, cross-sectional surveys (UAT) of Pregnant women attending public antenatal clinics, including in refugee camps At the time of the women's first visit to the camp, if blood is drawn for syphilis testing, left over blood is used For refugee women in some settings, syphilis testing has had to be set up in order to have leftover blood, like Sudan Often no informed consent is obtained because of Concerns of selection/participant bias The women’s identify is stripped except for Age, parity, marital status , educational level , and clinic location (or urban versus rural) And in refugee camps: refugee versus host status The method used, are Rapid, diagnostic tests and/or dried blood spots.

25 Reliability of HIV Testing: Rapid Tests vs. EIA
Gray RH, et al. BMJ, 2007, in Rakai, Uganda: 43.7% (129/295) false positive results 0.3% (4/1,222) false negative results UNHCR, 2006/07, Kenya PMTCT rapid tests EIA at National Public Health Lab HIV positive HIV negative Total Dadaab refugee camp, Aug-Jan Rapid test algorithm positive 1 Rapid test algorithm negative 9 1032 1041 10 1042 sensitivity=10%; specificity=100%; PPV=100%; NPV=99.1% Kakuma refugee camp, Kenya, Sept-Jan 7 13 20 1136 1145 16 1149 1165 sensitivity=43.8%; specificity=98.9%; PPV=35%; NPV= 99.2% And we need to remember that in refugee camp situations, the requirement of room temperature for rapid kits is often exceeded and methods for making and maintaining dried blood spots are not simple In a recent article by RH Gray in Rakai, Uganda, in non-refugee setting They observed almost a 45% false positive result 129 / 295 HIV positives and 4 (0.3%) of the 1,222 false negative results For the two most recent, ANC sentinel surveillance studies of UNHCR in Kenya we found varying degrees of sensitivity and at one site a poor positive predictive value of only 35%

26 Prevalence (95% CI*) Year Prevalence (95% CI)
Refugees Prevalence (95% CI*) Year Host population Prevalence (95% CI) Somalis in Dadaab camp, Kenya 0.6% ( ) 2003 Garissa, Kenya 26.0% 2002 1.4% ( ) 2005 11.0% 2004 1.0% ( ) 2006/7 Sudanese in Kakuma camp, Kenya 5.0% ( ) Lodwar, Kenya 18.0% 1.2% ( ) Immediately surrounding 3.6% ( ) Sudanese in Palorinya settlement, Uganda 1.0% ( ) 5.9% ( ) 5.4% ( ) 6.9% ( ) Sudanese in Kyangwali settlement, Uganda 2.7% ( ) 2.8% ( ) Hoima, Uganda 4.6% Burundis in Lukole camps, Tanzania 3.1% Kagera region, Tanzania 3.7% 1.6% Burundis in Mtabila and Muyovosi camps, Tanzania 4.5% Kigoma region, Tanzania 2.0% DRC refugees in Lugufu and Nyaragusu camps, Tanzania 2.5% 1.8% Kagera region, Tanzania DRC refugees in Gihembe camps, Rwanda 1.5% ( ) Byumba, Rwanda 6.7% ( ) Given these concerns what data are available I do not want you to spend much time on the busy slide but, just to show you where I got the data from

27 Refugee vs. Host Populations HIV Prevalence
Spiegel PB, et al. Lancet, 2007 plus newer data (2006/07) Data <1 year for both populations Kenyan camps Somali refugees, 2003,’’05, ‘07, rate <10-fold vs. nearby town Sudanese refugees, 2002 , ‘06/7, rate <3-fold vs. town or surrounding Uganda settlements Sudanese refugees , 2004, and ‘05, rate <4 fold vs. town or surrounding Tanzania camps Burundi refugees, 2002 , ‘03, rate variable (<2-fold in 1 camp in ‘02, ‘03 ; >2-fold in 2 camps in 2003) vs. nearby town DRC camp refugees Rwanda and Tanzania, 2002 and ‘03, respectively, rate <2-fold vs. towns So those data come from the study by Spiegel PB, et al. Lancet, 2007 plus newer data from 2006/07 of UN Refugee Agency for which I provided technical assistance Looking only at data within 1 year for both populations Among the 2 Kenyan camps, For the one with Somali refugees, surveys in 2003, 05, 07, found a rate <10-fold lower HIV prevalence rate when compared with the nearby town For the camp with Sudanese refugees, a survey in 2002 , 06/7, found a rate <3-fold lower HIV prevalence rate when compared with the nearby own in 2002 or surrounding residents in 2006/07 For Uganda settlements, Uganda has more of a settlement rather than camp situation Among Sudanese refugees, in 2004 and 2005, HIV prevalence rate was found to be <4 fold compared with the town or surrounding residents In Tanzania camps, among the Burundi refugees, In 2002 and 2003, rate variable were found, depending on which camps were surveyed, in 1 camp the rate was equal and then decreased 2-fold compared with the nearby town from 2002 to 2003 But in 2 other camps the refugees had a 2-fold greater HIV prevalence compared with the nearby town Among DRC camp refugees, either in Rwanda and Tanzania, in 2002 and 03, respectively, The HIV prevalence rate among the refugees was 2-fold less compared with the nearby towns

28 3. Do IDPs and refugees have the same HIV risks and prevalence rates?
And my final question, do internally displaced persons and refugees have the same HIV risks and prevalence rates

29 Additional Differences between Refugees and Internally Displaced Persons (IDPS)
Level of interface with Military and peacekeeping forces, and humanitarian aid workers Protection 1951 Refugee Convention 1967 Protocol Services Implementing partners vs. host population First I want to point out some additional differences between refugees and IDPs Level of interface with military and peacekeeping forces, and humanitarian aid workers, is often very different with IDPs having ongoing interactions with military and peacekeepers compared with Protection 1951 Refugee Convention 1967 Protocol Services Implementing partners vs. host population, for refugees the UN Refugee Agency is responsible for protection and establishing networks with different implementing partners to provide water, food, health services, education IDPs are at the mercy of the government and system that made them internally displaced

30 HIV Prevalence Studies on Internally Displaced Women
Luanda, Angola, 2000, at antenatal care and family planning clinics 1.8% HIV-infected among 1,035 This prevalence rate lower than most urban settings in Africa and Angola 52.6% of infected vs. 36.8% infected women engaged in business (NS) Usually street vendors Now looking at 3 recently published studies that looked specifically at Internally displaced women The first by Strand et al Took place in Luanda, Angola in 2000 among internally displaced women attending antenatal care and family planning clinics The HIV prevalence for these women of childbearing age was <2% This prevalence rate is much lower than most urban settings in Africa or Angola Although not significant more of those infected were working, than those not infected and usually they were street vendors Source: Strand R, et al. Int J STD & AIDS, 2007

31 Internally Displaced (IDWs) vs. Surrounding Population Women
Congo River area, DRC, 2005, in household survey 7.6% (95% CI 4.1, 11.0) vs. 3.1% (CI 2.1, 4.1) HIV prevalence Fewer married (84.7% vs. 95.4%, NS), lived without partners (13.9% vs. 6.2% , p<0.01) More reported history of sexual violence during conflict (11.1% vs. 1%, p<0.01) More reported STI symptoms in last 12mon (60.4% vs. 52.5%, p=0.02), more active syphilis (4.0% vs. 0.5%, p<0.01) 55 refugee women in surrounding area vs. IDWs Reported history of sexual violence during conflict (1.8% vs. 14.2%, p=0.01) Among refugees, HIV prevalence 7.3% (CI 0, 14.1) and active syphilis 1.8% The second recent study along the Congo River in the Democratic Republic of the Congo, compared internally displaced women to the surrounding population of women by doing a 2-stage cluster household survey The HIV prevalence rate in this survey found internally displaced women to have a significantly high rate of almost 8% as compared with women of the surrounding population And among these displaced women, fewer tended to be married and significantly more lived without partners 14% compared with 6% Also more displaced women reported history of sexual violence during the conflict (11% compared with 1%) Significantly more displaced women reported sexually transmitted infection symptoms in the last 12 months and more were found to have active syphilis Source: Kim AA, et al. AIDS Behav, 2009

32 Internally Displaced (IDWs) vs. Surrounding Population Women
North Uganda , 2005, at antenatal clinic for protected camp vs. surrounding population 6.0% vs. 11.6%, p<0.01, respectively Multivariate analysis Older women (AOR=2, p<0.01) Unmarried women (AOR=1.5, p=0.02) Partner with non-traditional (modern) occupation (AOR=1.62, p<0.01) Living outside protected camp (AOR=1.55, p<0.01) The last study was in north Uganda in 2005 at antenatal care clinics providing care for women in protected IDP camps or for women in surrounding population The IDP women had lower HIV prevalence, 6% compared with the surrounding population women, 6% vs. 11% In multivariate analysis Usual risk factors, such as older women, unmarried women and having a partner who employed in non-traditional occupation, like being clerks, businessmen, professionals, soldier, students Were associated with HIV infection And again, living outside protected camps was associated with HIV infection Source: Fabiani M, et al. Conflict Hlth, 2007

33 IDWs, Surrounding Population, or Refugee Women
Context means everything Angola: IDWs very low HIV prevalence DRC: IDWs with higher HIV prevalence vs. surrounding women Greater history sexual violence and STIs North Uganda: IDWs with lower HIV prevalence vs. surrounding women Protected camps Greater risk associated with usual factors So looking at these three populations, internally displaced women, women of surrounding population or refugee women The findings seem to vary with the context In Angola, the IDWs had very low HIV prevalence In DRC, the IDWs had an higher HIV prevalence than the surrounding women and they had greater odds of having a history of sexual violence and sexually transmitted infections And in north Uganda, the opposite was seen the IDW had a lower HIV prevalence compared with the surrounding population women These displaced women living in protected camps but the usual risk factors, such as older age, being unmarried, were associated with odds of being HIV infected

34 HIV: Key Risk Factors among Refugees
Key Factors HIV prevalence of country of origin HIV prevalence of surrounding host population Level of interaction between two populations Type and location of refugees Phase of emergency (conflict, post-conflict, development) Length of time: conflict, camp and services So lets try to put these data into a frame work Looking at these factors the central themes are HIV prevalence of country of origin of the refugees HIV prevalence of surrounding host population Level of interaction between these two populations Type and location of refugees (e.g., unaccompanied minor or female head of household and urban vs. camp) Phase of emergency (conflict, post-conflict, in development) Length of time: conflict, camp and its location, whether remote and services, if they do exist Modified from Spiegel PB. Disasters 2004

35 HIV: Factors Increasing Refugees’ Risk
Key Factors HIV prevalence of country of origin HIV prevalence of surrounding host population Level of interaction between two populations Type and location of refugees Phase of emergency (conflict, post-conflict, development) Length of time: conflict, camp, and services Increased Risk Behavioural changes Gender-based violence/ transactional sex Reduced services (health and community services, protection, food) Reduced education Now factors that would increase the risk of HIV among the refugees Are Changes in behaviour, regarding sexual practice or family structure Gender-based violence or forced sexual activities and transactional sex, in order to just survive and obtain food A Reduction in services (health and community services, such as condom districution, protection, food and fuel) A Reduction in education, including sexual education

36 HIV: Factors Decreasing Refugees’ Risk
Key Factors HIV prevalence of country of origin HIV prevalence of surrounding host population Level of interaction between two populations Type and location of refugees Phase of emergency (conflict, post-conflict, development) Length of time: conflict, camp, and services Increased Risk Decreased Risk Behavioural changes Gender-based violence/ transactional sex Reduced services Reduced education Decreased mobility Reduced accessibility Slowing down of urbanization Increased services and resources in host country Decreased survival of sick persons And factors that can decrease the risk of HIV infection include Decreased mobility and decreased sexual activity Reduced accessibility to other populations and living in remote areas Slowing down of urbanisation, and factors in urbanization that increase the likelihood of HIV exposure Increased services and resources in host country as compared with the country of origin

37 HIV in Emergencies: Prevention and Control
Provide early interventions to prevent spread Use Minimum Initial Service Package (MISP) Available at: Coordinate and implement MISP Prevent sexual violence Reduce HIV transmission Prevent excess maternal and neonatal mortality and morbidity Plan for comprehensive reproductive health services Promote ABC, especially C There have been measures set forth to try to provide early interventions to prevent the spread of HIV and other sexually transmitted infections One such package is the MISP or Minimum initial service package for reproductive health that provides kits of equipment and supplies as well as coordinated activities to implement during an emergency, either conflict or natural disaster. The objectives and activities are Identify organizations and individuals to coordinate and implement MISP by having overall reproductive health coordinator and focal point persons in camps and implementing agencies to make materials available Prevent sexual violence by ensuring that systems are in place to protect the population, particularly women and girls and Ensuring medical services for sexual violence survivors are available 3. Reduce HIV transmission by Enforcing universal or standard precautions, Providing free condoms and Ensuring a safe blood supply Preventing excess maternal and neonatal mortality and morbidity by Providing clean delivery kits to pregnant woman and midwifes Starting referral system for obstetric emergencies And plan in the future for comprehensive reproductive health services by Identifying future sites for the services Assessing capacity of staff and identifying training materials if needed Identifying channels for equipment and medication needs and procurements However, MISP is not always being implemented where needed. My branch is currently undertaking an assessment of its use in emergency settings As at the least the ABCs, especially condom availability need to be ensured in an emergency

38 HIV in Emergencies: Additional Prevention and Control
Additionally protect vulnerable sub-populations Layout camp conducive to protection Distribute of essential items: Easy access to cooking fuel Treat sexual transmitted infections (STIs) Interaction with STIs, especially ulcerative Use HIV and STI emergency guidelines TB and HIV requires integrated programs Other prevention and control measures should in Additionally Protecting vulnerable sub-populations by Ensuring a camp layout that is conducive to protection Distributing essential items, such as easy access to cooking fuel – women and girls have been raped when going a distance from the camp to obtain wood for cooking Treating sexually transmitted infections, that increase the risk of acquiring HIV during sexual activity

39 GUIDELINES for HIV/AIDS interventions in emergency settings
The sectors are: Coordination Assessment and monitoring Protection Water and sanitation Food security and nutrition Shelter and site planning Health Education Behavior communication change (BCC) HIV/AIDS in the workplace Available at: lib_pub_file/249_filename _guidelines-hiv-emer.pdf Kofi Annan qualified the HIV of the one of the greatest difficulties our generation must face. This guideline identifies 10 sectors and describes specific interventions on a sector-by-sector basis to face HIV in emergencies. It was developed by the a special Team of the Inter-Agency Standing Committee on the HIV in the emergencies. The sectors are: 1. Coordination 2. Assessment and monitoring 3. Protection 4. Water and sanitation 5. Food security and nutrition 6. Shelter and site planning 7. Health 8. Education 9. Behaviour communication change (BCC) 10. HIV/AIDS in the workplace

40 Overall HIV Planning for Conflicts – Prevention and Control
Include HIV/AIDS in humanitarian action plans Establish coordination mechanism Collect baseline data, analyze and monitor situation Prevent and respond to sexual violence and exploitation Provide education material and condoms to population and aid workers Ensure universal precautions and safe blood supply Integrate programming with water/sanitation, nutrition, reproductive health, TB So the overall HIV planning for conflicts, need to Include HIV/AIDS in humanitarian action plans Establish coordination mechanism Collect baseline data, analyze and monitor situation Prevent and respond to sexual violence and exploitation Provide education material and condoms to population and aid workers Ensure universal precautions and safe blood supply Integrate programming with water/sanitation, nutrition, reproductive health, TB

41 Post-Conflict Stage Integrate refugee issues into national HIV programs and policies Implement sub-regional HIV initiatives Combine humanitarian and development funding Once the emergency is over, the UNAIDS/UNHCR strategy to support HIV-related needs of refugees and host populations takes over This strategy is to Integrate refugee issues into national HIV programs and policies Implement sub-regional HIV initiatives Combine humanitarian and development funding

42 National HIV Strategic Plans (NSP), 2004 in African Asylum Countries*
Avail able NSP (N=29) NSP mentioned refugees (N=23) NSP stated activities for refugees (N=23) Unknown 21% (6) No 35% (8) No 57% (13) In 2004, a survey of the National HIV Strategic plans in African countries with at least 10,000 refugees Of the 29, 23 were available to Paul Spiegel at UNHCR Of these 23, 15 or 65% have mentioned refugees or 35% have not And almost 60% had no stated activities for refugees in their plans Yes 43% (10) Yes 65% (15) Yes 79% (23) * with >10,000 refugees in 2004 Source: Spiegel PB, et al. Int Conf AIDS, 2004, Jul 11-16, 15, abstract D12361 with modification

43 Global Fund Approved Proposals with HIV/AIDS Components in African Asylum Countries*
Proposals mentioned refugees (n=26) Proposals stated activities for refugees (n=26) No 10% (3) Yes 23% (6) No 58% (15) No 77% (20) Yes 90% (26) Yes 42% (11) At the same time, a receive of the global dund to fight HIV/AIDS, TB and malaria 4th round of countries with >=10,000 refugees 90% had their proposals approved Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria; 4th round inclusive * with >10,000 refugees Source: Spiegel PB, et al. Int Conf AIDS, 2004, Jul 11-16, 15, abstract D12361 with modification

44 Antiretroviral Therapy (ART) in Conflict-affected Settings
RATIONALE Life saving, essential treatment available in Africa (universal access) Shown to be feasible in conflict-affected settings 60% of refugees are in camps >10 years (2008) INTERVENTIONS Post-exposure Prophylaxis PMTCT Therapeutic, long term PEPFAR support Rwanda, Tanzania, and Kenya beginning 2008/09 DRC and Burundi not yet Source: Julius Kasozi, UNHCR, personal communication, Nov 2009 ARTs should be provided in stable conflict-affected settings Source: US Committee for Refugees and Immigrants. World Refugee Survey 2009.

45 HIV Care and Treatment – Implementing ART among Refugee and Displaced Persons
Emergency phase over (mortality: <1/10,000/d) Basis needs of shelter, water, sanitation, food met Essential clinic services and medications exist For large part of population Camp expected to remain stable (? length) Commitment to control and sustain finances (? length) Adequate laboratory, standard treatment, continuous drug supply, guarantee quality So now we know that TB is an important public health problem among refugee and displaced persons When do we implement TB control programs First, the emergency phase must be over, in other words the mortality must be less than one death per 10,000 population per day Basis needs have been met And essential clinic services and medications exist for a large part of the population, including women and children The camp must be expected to remain in place and stable for at least 9 months from the time the last person begins treatment, As we all know, starting and stopping treatment can have worse consequences than not starting at all And of course, there must be a commitment to control and sustain finances for at least 12 months And adequate lab, standard treatment with a continuous drug supply and good monitoring of the quality of all must be guaranteed

46 Summary HIV risk factors increase during conflicts
Risk does not mean transmission If populations are isolated and HIV levels are low, conflict may be protective HIV risk factors increase post-conflict Opening up trade, but still unemployment, and accessing previously isolated populations Early interventions needed to prevent explosive spread Interaction with STIs, TB and other diseases requires integrated interventions HIV, STI and TB emergency guidelines available HIV risks factors do increase during conflicts but increased risk does not necessarily mean increased transmission. If the populations are isolated and HIV levels are low, the conflict may actually be protective Post-conflict times can actually increase risk more by opening up trade but not having sufficient modern jobs and increasing access to previously isolated populatons

47 Thank You

48 The findings and conclusions in this presentation are those of the author and do not necessarily represent the views of the Centers of Disease Control and Prevention.


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